There has been controversy about the use of
medications to treat both children and adults with Attention Deficit Disorder
There have been articles debating whether Ritalin is over or under prescribed.
When people ask me about this, I tell them that I can only answer for the
children and adults that I have evaluated or treated. Yes, there probably are
some individuals who have received medication when some other treatment might
have been better. On the other hand, there are probably others who were not been
diagnosed for years and could have benefited from medication. Finally, even if
someone has attention deficit disorder (ADHD) and is on medication, is it the
best medication, dosage and timing?

Medication can be quite helpful if
prescribed in the right context. First the individual needs a thorough
evaluation. If medication is prescribed, it should be followed closely. Small
changes in timing and size of doses can make a difference.

Although Ritalin is the best known
medication for ADHD, there are a number of other useful medications. For
individuals who have an incomplete response to one medication, the doctor can
often work with the patient to find another medication or combination that does
control symptoms. Some of the secondary medications may require closer
monitoring during the initial phase of treatment.

Sometimes medication failure is due to
lack of communication between patient and doctor. (and sometimes school) The
doctor, patient and family should be clear about exactly which symptoms they
expect the medication to treat. Patients should ask questions. They should
inform the doctor if there are side effects or if the medication does not seem
to be working.

If medication is still not working as
expected, it may be time to re-evaluate the diagnosis. Individuals with ADHD may
also have other disorders at the same time. Anxiety and depression may
superficially resemble ADHD. Occasionally a medical illness may masquerade as a
psychiatric condition.

Medication can only take the individual
part of the way to recovery. Therapy, community support, coaching and the
individuals own determination are important parts of treatment.

This
article focuses on how to cope with every day occurrences in the lives of
families affected by ADHD (Attention Deficit Hyperactivity Disorder). Often, it
is the small considerations that make life easier or much more difficult for
such a family. At the end of this article, I will give a few links to web sites
and listserves which allow individuals to share their own experiences of "what
works." However, one should remember that each individual is unique (this is
doubly true for individuals with ADHD) and each family needs to work out its own
coping strategies.

What is ADHD and how does it show
itself in elementary-school aged children? The DSM-IV, the diagnostic manual of
the American Psychiatric Association, suggests that the behaviors fall into
three general categories. These are impulsivity, inattentiveness, and physical
hyperactivity. Not all individuals with ADHD have the hyperactive component.
Because other conditions, such as anxiety and learning disabilities, can mimic
ADHD, one must approach the diagnosis carefully.

Accepting the Diagnosis

Many families go through
a period of uncertainty during the time leading up to the eventual diagnosis.
The experience of "getting diagnosed" is powerful and can either be a blessed
relief or a crushing blow. Many parents experience this as a loss and need to go
through a process of mourning so that they can eventually accept their child as
he or she is. The classic stages of mourning, denial, anger, grief and
acceptance all apply here. Parents and teachers may have different perspectives
on this phase of the process of acceptance. The professionals need to be patient
with parents as they come to terms with their child's condition. They should not
be too quick to pathologize parents who become emotional or angry in meetings.
Some of the nicest, most conscientious parents may become angry and tearful in
meetings. Parents and children may go through repeated episodes of mourning as
they experience the effects of the ADHD in different settings and at different
ages.

Community support is
important during and after the time of the initial diagnosis. It is easy for a
family to become overworked or overwhelmed. At such a point, the family might be
tempted to withdraw into itself just when support is most needed. Extended
family can be an important source of support, but can sometimes also be a source
of tension. Parents often feel that extended family members do not understand
the situation. Educating grandparents and extended family can take time.

Behavioral Planning

In the home, structure
and behavioral planning are often helpful. One has to tread a careful line so
that one does not squelch the spontaneous child too much. Complex behavioral
plans may look good on paper, but often do not last long in the rush of the real
world. The key components to a good behavior plan are simplicity, consistency
and frequent rewards. A weekly reward does not mean much to an impulsive child
with a short attention span. If the child chooses to work toward a larger
reward, he should receive tokens as incremental steps toward the goal. The plan
should reward incremental improvements in behavior. Any plan that expects an
immediate cessation of undesirable behavior is doomed. The good plan is set up
so that the child is able to achieve some measure of incremental success the
first day.

Parents are often
tempted to use corporal punishment because they feel that nothing less will get
a child's attention. Actually, one should especially avoid such punishment in
ADHD children because they are impulsive and more likely to imitate a violent
act. One must be extra careful to avoid teaching them to resolve conflicts with
violence. Parents must also walk the tightrope of advocating for appropriate
accommodations yet also teaching their child to have a sense of personal
responsibility for their actions.

Childproofing

In many ADHD children,
particularly the hyperactive ones, there can be serious safety considerations.
Impulsivity is a common feature of ADHD and it may manifest itself in climbing
tall trees, getting into medicine cabinets, and playing with power tools. Their
motor hyperactivity makes them quite fast, and they can be into tremendous
trouble in the time it takes a parent to load laundry into the washing machine.
Some ADHD children have coordination and balance disorders, but do not have the
judgement to accommodate to their difficulties.

Many people think of
childproofing as only for families with babies. All families should probably
childproof to some extent until everyone goes to college. This is especially
important for families affected by ADHD. Many family crises could be minimized
if valuable breakable objects were locked safely away. Certain stain-repellant
paints, vinyl wallpaper, and carpet treatments make accidents less costly.
Linoleum with the pattern printed through the entire thickness of the material
is less likely to show scratches. Sometimes one can plan indoor traffic patterns
to keep muddy feet off certain surfaces.

Although a family may
have their own house well childproofed, the grandparents may not have their
breakables out of the way. It is often best to discuss childproofing plans
before the visit. If it is not possible to get the breakables out of the way,
bring your own games and toys, or plan to play outside as much as possible.

Dealing with emergency rooms.

Children with ADHD are
at increased incidence of injuries and fractures. ER personnel refer to
individuals who turn up repeatedly as "frequent fliers." If you have an
accident-prone child, have an emergency plan. One parent taking an injured child
and two other active children to an emergency room can itself be dangerous. Are
there neighbors who could watch the other kids while you seek medical care? Ask
your pediatrician to recommend the best emergency room. Some emergency rooms are
better than others at handling injured children. If ER personnel are especially
nice, write a nice thank-you letter to the administrator of the ER. Same to
ambulance crew etc. Multiple or odd fractures can raise the issue of child
abuse. Being investigated for child abuse can be humiliating and adds to the
stress of dealing with an injured child. Discuss this in advance with your
pediatrician and make sure the pediatrician calls the ER to let them know you
are on your way. Insist that the emergency room physicians contact your
pediatrician so that he or she can discuss the case with them. If you do get
investigated, try to be calm. Have a spouse or close friend with you for
emotional support.

Medication

Medication is often an
important part of the comprehensive treatment of an individual with ADHD. This
article will not focus on the variety of medications available today. However, I
do want to cover a few important points. Ritalin is the most commonly prescribed
medication for ADHD. It is important to remember that it is a short-acting drug
and only lasts 2.5 to 4 hours. Often children are given a morning dose at 7AM
before leaving home and do not get their second dose until Noon. If this is how
your child's medication is scheduled, check to make sure that he is doing well
in the two hours before lunch. Some children may experience a rebound effect as
the medication wears off. If there is a problem during this period, talk to your
child's doctor about adjusting the timing of the medication doses or switching
to a different medication. Sometimes a small change in the timing of Ritalin
dosing can make a big difference. There are a number of medications that can be
helpful for ADHD if the stimulants are not sufficient. If the current regimen is
not adequate, a comprehensive psychiatric evaluation may clarify the roles of
both medication and other interventions.

Part of dealing with
medication is dealing with the issue of stigma. Some children may think that
only the "bad" kids go to the nurse to get stimulants. Other children enjoy
their daily visits to the nurse. When students line up to see the nurse, the
students sometimes figure out who is getting the Ritalin. For some sensitive
children, this may be a reason to consider other medications. In other cases,
some general classroom education about ADHD and medications may suffice.

Siblings

Siblings may feel
ignored when parents are focusing on the ADHD child. It is important to keep the
needs of the other siblings in mind. It is useful to allow the siblings to vent
their feelings privately. They may also feel less of a sense of injustice if
they are educated about ADHD. There are several good books to read with the
siblings. (See below.) They should also be counseled about how much they can
tell their friends about their ADHD sibling.

Confidentiality and disclosure

Whom do you tell about
the diagnosis and condition? This is a judgement call. Often it is best to
consult the child about this. Many times, it is better to allow friends and
their parents to get to know your child before telling them. That way, they know
your child as a person before they can stereotype him.

How much do you tell
your child's school? (before and after admission) This, too is a judgement call.
Generally it is a good idea to let the school know if your child has any special
needs. However, this can be a particularly thorny issue if your child is
applying to a competitive private school. Some schools are more understanding
about ADHD than others. If 100 children are applying for ten slots, a few
schools might not spend the time to understand your child's unique situation.
Talk to other parents and get a feel for how the school personnel deal with
these issues. If you know the parent of an ADHD child who attends the school,
they might be able to give you advice. If your child is currently attending a
particular school, one should be sure to tell the school nurse about any
medications, even if they are given at home. Children do have accidents at
school and the information should be available for emergencies.

Advocating for Your Child's Educational Needs

When advocating for your
child, try to start off with a positive attitude. Be aware of your child’s
educational and legal rights, but do not start off by quoting the law to staff.
For children in the public schools, there is specific, legally mandated system
to help determine the child's educational needs. If you feel that your child
needs educational testing or special education resources, ask for an ARD
meeting. Often parents can assist the school in gathering information to
determine whether the child needs testing or special help. If your child has a
special educational plan (IEP), always review it carefully before the formal
meeting. If possible, both parents should come to the meeting. If one parent is
feeling angry or frustrated, try to have the calmer parent do the talking. If
the special education process is confusing, you may seek out an educational
advocate to come to the meeting with you. If the school does the testing, you do
not have to pay for it. You may obtain outside evaluations, at your own expense,
to bring to the school meeting.

If you have the time and
energy, try to volunteer time for your child’s school. Volunteers can free up
some of the teacher’s time. This may, indirectly, give her more time to focus on
your child's needs. This also gives the parent an opportunity to get to know the
school environment and some of the child's classmates. Having a good knowledge
of the functioning of your child's school can help clear up potential
misunderstandings.

Some parents choose to
arrange for private evaluations or tutoring. Speech therapy, occupational
therapy and some other services may be covered by some insurance plans. Some
companies have dependent medical care plans which allow the parent to put
pre-tax money aside for medical and child care expenses. This can be used to
cover certain kinds of assessments and treatments not covered by insurance or
paid by the school. Check with your employer or tax specialist. Many private
schools have arrangements with tutors and speech therapists. In these cases, the
parents usually pay for the services. In some situations, a child in a private
school may qualify for free services funded by the public schools. In this case,
the parent usually has to drive the child to a public school to get the services
there.

Ultimately the most
important thing is to instill in your child a positive self-esteem and an
attitude of responsibility and mastery. The child should be encouraged to learn
all he can about ADHD. At the same time, the child should take responsibility
for his actions.

References

1. You Mean I’m Not Lazy, Stupid or Crazy?
By Kelly and Ramundo

2. Driven to Distraction by Hallowell and
Ratey

3. The Hyperactive Child, Adolescent and
Adult Attention Deficit Disorder Through the Lifespan by Wender

4. Attention Deficit Disorder, A
Different Perception by Hartmann

5. ADHD in the Schools, Assessment and
Intervention Strategies by DuPaul and Stoner.

Our practice has experience in the treatment of Attention
Deficit disorder
(ADD or ADHD), Depression, Separation Anxiety Disorder,Obsessive-Compulsive
Disorder, and other
psychiatric conditions. We are located in Northern Baltimore County and serve the
Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near
the Pennsylvania border, we also serve the York County area. Our
services include psychotherapy, psychiatric evaluations, medication management, and
family therapy. We treat children, adults, and the elderly.